1 What is your age group?

Under 18 19-39 40-50 51+

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2 Without my glasses and contacts... (Check All That Apply)

Without my glasses and contacts

Farsightedness : I have trouble reading and seeing things up close‎ Nearsightedness : I have trouble driving and seeing things far away‎ Astigmatism : I have distorted vision and cannot see very well‎

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3 What do you usually wear? (Check All That Apply)

What do you usually wear?

Glasses‎ Contacts‎ Reading Glasses‎ None of Them‎

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4 Do you have any of the following? (Check All That Apply)

Do you have any of the following?

Cataracts‎ Keratoconus‎ Diabetic Retinopathy‎ Prior Eye Surgery‎ Prior serious eye injury‎ Are you pregnant or nursing?‎ None of the above‎

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5 I would like to see well at a distance without relying on glasses and contact lenses.

I would like to see well at a distance without relying on glasses and contact lenses.

Yes No

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6 I would like to see well up close without relying on glasses and contact lenses.

I would like to see well up close without relying on glasses and contact lenses.

Yes No

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7 Would your lifestyle improve if you were to become less dependent on glasses and contact lenses?

Would your career or business activities improve if you were to become less dependent on glasses and contacts?

Yes No

Test Score

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8 Would you like to be contacted by an Evergreen Eye Center team member?

Would you like to be contacted by an Evergreen Eye Center team member

Yes, Please Call Me No, I'm Not Ready

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